Healthcare Provider Details

I. General information

NPI: 1043401672
Provider Name (Legal Business Name): KEVIN R KENERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 S FREEPORT RD SUITE 2A
FREEPORT ME
04032-6145
US

IV. Provider business mailing address

174 S FREEPORT RD STE 2A
FREEPORT ME
04032-6145
US

V. Phone/Fax

Practice location:
  • Phone: 855-239-3556
  • Fax: 207-512-5909
Mailing address:
  • Phone: 207-307-0958
  • Fax: 207-512-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2105
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number2105
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: